Clinton Plan Will Restrict Health Care Choice

Published: September 26, 1993

To the Editor:

President Clinton's claim in his speech to Congress that his proposed reform will broaden Americans' health care choices is deceptive. His plan would in effect obliterate private practice and other small-scale providers, leaving patients to choose from a menu offering only corporate care served up by insurance giants like Prudential and Aetna.

The President hopes to control costs through the rapid expansion of large, competing health maintenance organizations. But despite the Clinton assurances that other health insurance options will remain available, private practice cannot possibly coexist with a dominant H.M.O. sector.

Big health maintenance organizations skimp on doctors, employing about 1 physician for every 800 enrollees, often meaning long waits for hurried consultations. In contrast, for the country as a whole, the physician-to-population ratio is 1:400.

Hence, H.M.O. expansion would absorb many patients but few physicians. The result: a glut of doctors (mostly specialists) in private practice serving a shrinking pool of patients. Initially, doctors might increase fees to meet their overhead and maintain their incomes, but increasing fees would accelerate the movement of patients into health maintenance organizations.

The Princeton economist Uwe Reinhardt has noted that if half of Americans enrolled in health maintenance organizations with 1 doctor per 800 enrollees (and competitive pressures would drive health maintenance organizations to keep physician staffing to the minimum), each remaining private physician would serve an average of only 267 patients, too few to cover even office overhead.

At some point private practice would completely collapse, leaving tens of thousands of doctors scrambling. At the limit, if all Americans enrolled in health maintenance organizations, about 275,000 doctors, most of them specialists, would be stranded in a private practice sector devoid of patients. Competition for H.M.O. jobs would be fierce, the disruption of care massive.

The President's spin doctors portray his proposal as assuring a pluralistic health care system, with patients choosing the kind of care they want and doctors free of micro-management. But simple calculations belie this image. Instead, a few insurance giants would dictate care.

The Canadian alternative is far preferable. Everyone is covered, quality of care is high, patients can freely choose and change doctors, and physicians are free to choose from a variety of practice settings. Costs have been contained by streamlining bureaucracy (largely by evicting insurance companies from the system) and by a simple budgeting system, rather than the Rube Goldberg devices proposed by Mr. Clinton.

President Clinton's plan would sacrifice the health care of those who are now satisfied. It can't contain costs and hence won't extend coverage. But it will complete the corporate transformation of American medicine. DAVID U. HIMMELSTEIN, M.D. STEFFIE WOOLHANDLER, M.D. Cambridge, Mass., Sept. 23, 1993 The writers, associate professor and assistant professor of medicine, respectively, at the Harvard Medical School, are co-directors of Harvard's Center for National Health Program Studies.